Just about every function of a digital health record depends upon a unique, precise and persistent patient identification... one-patient-one-chart. This identification needs to accommodate how patients wish to be referred to as well as how they are recognized by diverse information systems that need to communicate with one another. This section points to resources that might be needed when questions of patient identity arise.
The top of the left column (StoryBoard) in any patient chart (Hyperspace) shows the patient's "affirmed" (preferred) name, immediately below a space for an identifying photograph. Hovering over the patient's name opens an information bubble with specific identifying information, including affirmed and administrative (legal) names, unique identifiers and contact information.
Important unique identifiers include:
MRN (Medical Record Number) - Provincial identifier (assigned by Connect Care for Alberta Health Services [AHS])
ULI (Unique Lifetime Identifier) - Provincial identifier (assigned by Alberta Health for medical services), often needed for seeking patient information in other provincial systems (e.g., Netcare)
CSN (Contact Serial Number) - Connect Care identifier unique to a particular encounter (inpatient, outpatient, emergency, etc.) for a particular patient
Clicking on the patient name (in StoryBoard) opens a "Demographics" activity (also easily found by entering "demo" in Chart Search, then selecting "Jump to Demographics" where much more information can be found and edited. Most of this information should be left to admitting, reception, ward or clinic clerks, but some can be easily added or corrected by prescribers:
Email - Appearing within the "Contact Information" tab, is needed for the prescriber to issue a patient portal (MyAHS Connect) activation message facilitating patient sign-up
Contacts - Appearing within the "Additional Information" tab, allows one or more designated patient contacts (next of kin, family spokesperson, etc.) to be added to facilitate communications
AHS respects how patients may want to be identified and referred to when interacting with the health care system or its communications. Clicking on the patient gender/age line within StoryBoard opens a "Sexual Orientation and Gender Identity Expression" (SOGI or SOGIE) activity (SmartForm). This indicates the patient's administrative gender (legal sex) used by health information systems that Connect Care may need to exchange information with. It also reflects information that patients may provide through MyAHS Connect or directly to healthcare providers about:
Gender Identity - Affecting how gender information is displayed in most communications
Pronoun Preference - Affecting a set of inclusive SmartLinks and SmartPhrases that bring this preference into communications
Sex Assigned at Birth - Important to some decision supports and clinical documentation tools
Sexual Orientation - Reflecting whether and how a patient would like to be represented
Organ Inventory - Reflecting any genetic or interventional anatomic changes that could affect clinical decision-making
Administrative gender (legal sex) is recorded as indicated on government issued identification at the time of registration. It is mandatory and affects system-to-system interfacing and required reporting. Gender identity may be provided or revised by prescriber (in consultation with the patient) at any time and should be respected in documentation and communications thereafter. Sex at birth is information that may be collected when clinically relevant.
Some of the values assigned to these attributes can be changed by prescribers in consultation with the patient. The organ inventory embedded in the SOGIE SmartForm can be completed by any clinician and should accurately reflect reproductive organs present or removed.
Key SmartLinks (dot phrases)
.GENDERP - patient's gender identity in prose-friendly form
.IDENTITY - returns a concise prose-friendly text summarizing all selections from the SOGIE SmartForm that relate to patient gender preference, gender assigned at birth, sexual orientation and pronoun preferences. Dark blue hyperlinked text within can be used to quickly access the SmartForm and make edits.
.ORGANS - returns a concise prose-friendly text summarizing the SOGIE reproductive organ inventory. Dark blue hyperlinked text within can be used to quickly access the SmartForm and make edits.
Other Gender, Pronoun and Identity SmartTools
A portrait (face) photo can be added to the chart to facilitate patient identification. Such visual identification can reduce a variety of errors, particularly in wards with large patient numbers and especially for patients with common names. Patients can add or change their own photo using MyAHS Connect.
Clinicians can add an identification photo by using a mobile device running a Connect Care application (Haiku or Rover). Tapping the patient's portrait icon at the top left of the chart initiates an image capture workflow that is easy to follow. Special consent is not required. The patient should be informed that the image is used to facilitate identification in the digital health record, helping to avoid error. Patients may refuse verbal consent to proceed.
Unknown Patient Identity
Sometimes patients are admitted before their identity can be reliably confirmed, as might happen with altered states of consciousness. They are assigned an anonymous name, chart and record numbers so that care can proceed. The default last name will start with the letters "UNK-" and the default first name is randomly assigned from a pool.
As soon as an unknown patient is formally identified, a nurse or clerk informs patient registration so that chart corrections can be made. This starts a process for moving new information from the anonymous to the permanent chart. If the affected patient is admitted, the anonymous chart remains in use until discharge. Health Information Management (HIM) is involved to sort out a potentially complex merge of anonymous with permanent health record content.
When unknown patients are admitted to a Connect Care facility, it is likely that clinicians will be working from a temporary (anonymous) Connect Care chart. The patient's legal name will have assigned values for first and last (UNK-) names. The correct first and last names are entered to the anonymous chart as "preferred" names when patient identification is confirmed. Accordingly, it is important that Connect Care users make use of appropriate SmartLinks in all documentation, including any personal SmartPhrases. The following SmartLinks work best, as the true patient name is reflected upon identification, even while a temporary chart is still in use:
First name: ".PREFNAMEFIRST" or ".PREFNAME"
Last name: ".PREFNAMELAST"
Full name: ".PREFNAMEFULL"
Incorrect Patient Identity
More rarely, patients may intentionally provide an incorrect identity when seeking health services. HIM should be alerted to an incorrect identity as soon as possible, as there are even greater challenges getting the correct information reassigned to the correct chart.
Prescribers can use the "Chart Correction" link (top right of Hyperspace when a chart is open). This provides access to a chart correction guide and a message for requesting a chart correction.